Uncontrolled hypertension is emerging to be a frequent clinical issue, with 10% of the hypertensive complication found to be uncontrollable (Beckett, Peters & Fletcher, 2008). This condition may lead to severe damage to renal, cerebral and cardiovascular organs of the body (KSchirpenbach & Reincke, 2009; Perera, 2005). It is caused by poorly controlled blood pressure, attributed to medical non-compliance, insufficient antihypertensive medication, and white-coat hypertension, and between 4 and 19% of arterial hypertension patients is therapy-resistant hypertension; defined as failure to achieve target blood pressure (Toprak, Wang & Chen, 2009).
Natarajan, Santa, Liao, Lipsitz & McGee (2009) investigated the effect of treatment and adherence on ethnic differences in hypertension control among adults in the United States and revealed that the likelihood of uncontrolled hypertension was higher in non-Hispanic blacks despite adhering to the medical treatment prescription, and even adjustment for treatment did not significantly change ethnic differences.
This paper reviews and critically analyses some of the present evidence-based strategies for preventive management and care for African-American males with uncontrolled hypertension who are non-compliant to medication. PICO analysis is used to provide the format and guidelines. The result is expected to benefit primary care nurses as well as assist the patients to identify the early stages of hypertension for early assistance and treatment.
Problem to be addressed
In my practice as a primary care nurse, I have attended to an unequaled number of African-American males with uncontrolled hypertension who are non-compliant with medical treatment. These scenarios have intrigued me and the feeling of insufficiency and need for a solution has prompted this study. There are quite a several published studies indicating some significant variance in the level of compliance and non-compliance across the ethnic groups.
For example, in a study conducted by Natarajan et al. (2009) that investigated the effect of treatment and adherence on ethnic differences in hypertension control among adults in the United States, it was established that the likelihood of uncontrolled hypertension was higher in non-Hispanic blacks despite adhering to the medical treatment prescription, and even adjustment for treatment did not significantly change ethnic differences. This shows a clear level of disparity of people at risk.
PICO format will be applied in the design of the question to be addressed.
- Patients: the patients in question are African-American males with uncontrolled hypertension who are non-compliant to medication;
- Intervention: the intervention is to use evidence-based intervention practices for the treatment and care of African- American males with uncontrolled hypertension who are non-compliant with medication. This calls for intensive education for the group;
- Comparison: the patients’ and the nurses’ knowledge will be analyzed and compared; the missing link will be identified. Also, a nurse-led intervention will be compared with conventional care treatment.
- Outcome: the expected outcome of the analysis is to deduce a well-structured and evidence-based approach to improve the management and care for these patients and boost their level of compliance, hence controlling blood pressure among this high-risk population.
In a nutshell, what is the best practice for treatment and care of medically non-compliant African Americans with uncontrolled hypertension?
Methodology and Results for Search
In the study, a search was basically on online articles, with a specific focus on Medline, CINAHL databases, and Google Scholar. However, some print articles were also used to further back up the online resources.
Medline: In this database, there were several options for search namely: Main Search Interface, Simple Search, Advanced Search, Search Specific Journals, and browse or search MEDLINE by MeSH Terms. I opted for the simple search option that gave me an open option of using plain English to find articles of my interest (i.e. related to hypertension) e.g. “tell me about hypertension”, “managing uncontrolled hypertension”. This is large because I did not have any particular article in mind to specify my search. Again it allowed me to choose from the latest and wide range of relevant material, that is, the most recent materials. Medline classify the materials published later than 2005 as “In-progress”.
The result found one interesting article entitled; “Why don’t you do as I tell you?” Compliance and antihypertensive regimens (Hansson, 2002). This article reviewed some of the reasons for non-compliance with treatments, specifying antihypertensive medication (Hansson, 2002). It states that one of the reasons for low compliance is the impact of a drug on a patient’s lifestyle; hence with recently developed agents such as angiotensin II-receptor may be expected to have less effect on patients’ daily lives than earlier treatments (Hansson, 2002). Another reason for this non-compliance is the nurses’ inadequate knowledge of the treatment procedure. According to PICO, the C for comparison, the patient’s lifestyle, as well as nurse’s knowledge, is comparative factors to be considered when designing an intervention program.
CINAHL database: this database offered a lot of search options such as basic search, advanced search, and visual search. My efforts to use the advanced search option were not successful with results either not sufficient and/ or not available. The basic search generated a wide range of results that I had to peruse to identify the most relevant ones. The search terms used in this general search were: “uncontrolled hypertension”, “uncontrolled hypertension control”.
Several results were shown but one article proved to be very significant in this review; Management of uncontrolled hypertension in a nurse-led clinic compared with conventional care for patients with type 2 diabetes by Denver, Barnard, Woolfson & Earle (2003). 120 men and women outpatient attendees (61% non-Caucasian) with type 2 diabetes and seated blood pressure were studied (Denver et al. 2003).
The result showed a change in blood pressure for was more in a group of patients led by nurses, with a three-fold possibility of this group reaching the target systolic blood pressure as compared with conventional care (Denver et al. 2003). Again, a ten-year CHD and stroke risk scores fall was only observed in the nurse-led group (Denver et al. 2003). Significantly, there were no differences in the reduction of diastolic BP or any of the other secondary outcome measures at 6 months (Denver et al. 2003).
In PICO analysis, the two approaches compared, the nurse-led hypertension clinic is a more effective intervention for patients with type2 diabetes and uncontrolled hypertension. This is because a target systolic blood pressure among the African- American men can be readily reached and is likely to be associated with a significant reduction in 10-year cardiovascular disease risk scores (Denver et al. 2003). However, because other studies have revealed that nurses have limited education on management and care of this group of patients, it calls for a drastic intervention that would ensure the nurses get adequate education and skills to enable them to cope (Law, Wald, Morris & Jordan, 2003).
Google Scholar: being one of the most popular and free search engines, it was very helpful for its ability to generate numerous relevant results. The search terms used were: “hypertension prevalence in the US” and “uncontrolled hypertension”. There were numerous search results. One study by Hajjar & Kotchen (2003) entitled: Trends in [prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000 was very significant. The survey was done using a stratified multistage probability sample of the civilian non-institutional population. Only individuals 200 people over 18 years were involved (Hajjar & Kotchen, 2003).
A multiple regression analysis revealed that there was an age increase, a rise in body mass index, and most importantly, non-Hispanic black was in one way or another associated with the increased hypertension prevalence (Hajjar & Kotchen, 2003). The study further revealed that in 1999- 2000, 68.9% were aware of hypertension, the number treated of hypertension rose by 6%, and the number of cases controlled increased by 6.4% (Hajjar & Kotchen, 2003).
It is significant to note that hypertension is increasing in the United States, especially among African Americans, yet rates of control are still low and programs that are tailored towards creating awareness to prevalence are very critical (Cook, Obarzanek & Cutler, 2009). The PICO question targets the African American population; the intervention is to create more awareness through education programs; the comparison between the number of cases treated and the number controlled shows that the number controlled was slightly higher than the number treated.
A full article review by Chobanian (2009) entitled The hypertension paradox- more uncontrolled disease despite improved therapy, states that despite the remarkable medical advancements with a new therapy, hypertension continues to rise and pose a major public health problem. That the number of people with high blood pressure continues to rise and ostensibly, their life expectancy reduces by an averagely 5 years (Chobanian, 2009).
The most recent studies among the age group of 80 and above, who got their treatment with a diuretic and an ACE inhibitor, were linked to a significant decrease in mortality and morbidity from cardiovascular diseases. Furthermore, a placebo-controlled trial showed that stroke incidence can be reduced by between 35 and 40%, the incidence of the coronary event reduced by between 20% to 25%, and congestive heart failure incidences decreased by more than 50%. The treatment is also associated with reduced malignant hypertension and minimal cases of acute hypertensive heart failure and hemorrhagic stroke are now uncommon.
However, Chobanian (2009) emphasizes the need to embrace new evolving approaches of treatment for example lifestyle modification. It has been recommended numerous times that lifestyle modifications provide the opportunity to reduce hypertension. According to PICO, I would summarize such lifestyle changes in intervention efforts as exercise, restricting sodium intake and improving potassium intake, alcohol consumption moderation, practicing Dietary Approach to Stop Hypertension (Dash).
Finally, the outcome from PICO would show that when these behavioral habits are modified, then the men at risk are likely to decrease their systolic blood pressure by between 5 to 10 mm Hg with a corresponding weight reduction of 10kg. With this, a well-framed intervention would ensure the nurses get adequate education and skills to enable them to cope with the ever-increasing challenges of this disease (Law, Wald, Morris & Jordan, 2003).
From the review above, one of the articles is recommended for implementation Denver, Barnard, Woolfson & Earle’s (2003) article; Management of uncontrolled hypertension in a nurse-led clinic compared with conventional care for patients with type 2 diabetes. In the PICO question, first, this study showed more similarity with my target group of the population of African Americans ethnic group (61% non-Caucasian).In primary healthcare nurses, education is very crucial as shown in this study. The nurse-controlled clinic emerged as the best option, emphasizing the importance of interventions from the nurse’s perspective. The approach also compared the two approaches, the nurse-led clinic, and the conventional medicine approach. The outcome was positive with the nurse-led clinic giving a better result.
One study by Hajjar & Kotchen (2003) entitled Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000 was very significant too. I would recommend it for some exhaustive perspective using the PICO format. It revealed that the rates of control for hypertension are still low despite the increasing prevalence. It is established that the fact that nurses have limited education on management and care of this group of patients, calls for a drastic intervention that would ensure the nurses get adequate education and skills to enable them to cope (Law, Wald, Morris & Jordan, 2003). The patients also need to be more aware of hypertension to ease the identification at the early stages for early treatment.
The PICO question targets the African American population; the intervention is to create more awareness through education programs; the comparison between the number of cases treated and the number controlled shows that the number controlled was slightly higher than the number treated.
Beckett, N.S., Peters R., & Fletcher A.E. (2008). Treatment of hypertension in patients 80 years of age or older. N Engl J Med; 358:1887-1898.
Chobanian, V.A. (2009). The Hypertension paradox- more uncontrolled disease despite improved therapy. The New England Journal of Medicine. No.9. Vol.361:878-887.
Cook, N.R., Obarzanek E., & Cutler J.A. (2009). Joint effects of sodium and potassium intake on subsequent cardiovascular disease: the Trials of Hypertension Prevention follow-up Study. Arch Intern Med; 169:32-40.
Denver, E.A., Barnard M., Woolfson R, G., & Earl K.A. (2003). Management of uncontrolled hypertension in a nurse-led clinic compared with conventional care for patients with type2 diabetes. Web.
Hajjar, I., & Kotchen T.A. (2003). Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA; 290:199-206. Web.
Hansson, L. (2002). “Why don’t you do as I tell you?” Compliance and antihypertensive regimens. Int J Clin Pract Vol.56(3), pp.191-6. Web.
KSchirpenbach, C., & Reincke, M. (2009). Epidemiology and etiology of therapy resistant hypertension. Internist (Berl); 50(1):7-16. Web.
Law, M.R., Wald N.J., Morris J.K., & Jordan R.E. (2003). Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomized trials. BMJ; 326:1427-1434.
Natarajan, S., Santana E.J., Liao Y., Lipsitz S.R., & McGee D.L. (2009). Effect of treatment and adherence on the ethnic difference in blood pressure control among adults with hypertension. Web.
Perera, G.A. (2005).Hypertensive vascular disease: description and natural history. J Chronic Dis; 1:33-42.
Toprak, A, Wang H., & Chen W. (2009). Pre-hypertension and black-white contrasts in cardiovascular risk in young adults: Bogalusa Heart Study. J Hypertens; 27:243-250.